Healthcare Provider Details

I. General information

NPI: 1669455192
Provider Name (Legal Business Name): MICHAEL A THURSBY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2005
Last Update Date: 08/11/2020
Certification Date: 08/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

318 WATERMAN AVE
EAST PROVIDENCE RI
02914
US

IV. Provider business mailing address

318 WATERMAN AVE
EAST PROVIDENCE RI
02914-3525
US

V. Phone/Fax

Practice location:
  • Phone: 401-438-5950
  • Fax: 401-435-6700
Mailing address:
  • Phone: 401-438-5950
  • Fax: 401-435-2245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number213316
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number00502
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: